Coventry Health Care of Louisiana

Pages 1--64 from Coventry Health Care of Louisiana

Serving: The New Orleans, Slidell and Baton Rouge area
Enrollment in this Plan is limited. You must live or work in our Geographic service area to enroll. See page 8 for requirements.
Enrollment codes for this Plan:
Baton Rouge area JA1 Self Only
JA2 Self and Family
New Orleans area BJ1 Self Only
BJ2 Self and Family

A Health Maintenance Organization

RI 73-244
For changes
in benefits,
See page 9. 1.
1 Page 2 3
Dear Federal Employees Health Benefits Program Participant:
I am pleased to present this 2004 Federal Employees Health Benefits (FEHB) Program plan brochure. The brochure
describes the benefits this plan offers you for 2004. Because benefits vary from year to year, you should review your
plan's brochure every Open Season – especially Section 2, which explains how the plan changed.

It takes a lot of information to help a consumer make wise healthcare decisions. The information in this brochure, our
FEHB Guide, and our web-based resources, make it easier than ever to get information about plans, to compare
benefits and to read customer service satisfaction ratings for the national and local plans that may be of interest. Just
click on www. opm. gov/ insure!

The FEHB Program continues to be an enviable national model that offers exceptional choice, and uses private-sector
competition to keep costs reasonable, ensure high-quality care, and spur innovation. The Program, which began in
1960, is sound and has stood the test of time. It enjoys one of the highest levels of customer satisfaction of any
healthcare program in the country.

I continue to take aggressive steps to keep the FEHB Program on the cutting edge of employer-sponsored health
benefits. We demand cost-effective quality care from our FEHB carriers and we have encouraged Federal agencies
and departments to pay the full FEHB health benefit premium for their employees called to active duty in the Reserve
and National Guard so they can continue FEHB coverage for themselves and their families. Our carriers have also
responded to my request to help our members to be prepared by making additional supplies of medications available
for emergencies as well as call-up situations and you can help by getting an Emergency Preparedness Guide at
www. opm. gov. OPM's HealthierFeds campaign is another way the carriers are working with us to ensure Federal
employees and retirees are informed on healthy living and best-treatment strategies. You can help to contain
healthcare costs and keep premiums down by living a healthy life style.

Open Season is your opportunity to review your choices and to become an educated consumer to meet your healthcare
needs. Use this brochure, the FEHB Guide, and the web resources to make your choice an informed one. Finally, if
you know someone interested in Federal employment, refer them to www. usajobs. opm. gov.

Sincerely,

Kay Coles James
Director 2.
2 Page 3 4
Notice of the Office of Personnel Management's
Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED
AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE
REVIEW IT CAREFULLY.

By law, the United States Office of Personnel Management (OPM), which administers the Federal Employees Health
Benefits (FEHB) Program, is required to protect the privacy of your personal medical information. OPM is also
required to give you this notice to tell you how OPM may use and give out (" disclose") your personal medical
information held by OPM.

OPM will use and give out your personal medical information:
. To you or someone who has the legal right to act for you (your personal representative), . To the Secretary of the Department of Health and Human Services, if necessary, to make sure your privacy is
protected,
. To law enforcement officials when investigating and/ or prosecuting alleged or civil or criminal actions, and . Where required by law.

OPM has the right to use and give out your personal medical information to administer the FEHB Program. For
example:

. To communicate with your FEHB health plan when you or someone you have authorized to act on your behalf asks for our assistance regarding a benefit or customer service issue.
. To review, make a decision, or litigate your disputed claim. . For OPM and the General Accounting Office when conducting audits.

OPM may use or give out your personal medical information for the following purposes under limited circumstances:
. For Government health care oversight activities (such as fraud and abuse investigations), . For research studies that meet all privacy law requirements (such as for medical research or education), and
. To avoid a serious and imminent threat to health or safety.
By law, OPM must have your written permission (an "authorization") to use or give out your personal medical
information for any purpose that is not set out in this notice. You may take back (" revoke") your written permission
at any time, except if OPM has already acted based on your permission.

By law, you have the right to:
. See and get a copy of your personal medical information held by OPM. 3.
3 Page 4 5
. Amend any of your personal medical information created by OPM if you believe that it is wrong or if information is missing, and OPM agrees. If OPM disagrees, you may have a statement of your disagreement
added to your personal medical information.
. Get a listing of those getting your personal medical information from OPM in the past 6 years. The listing will not cover your personal medical information that was given to you or your personal representative, any

information that you authorized OPM to release, or that was given out for law enforcement purposes or to
pay for your health care or a disputed claim.
. Ask OPM to communicate with you in a different manner or at a different place (for example, by sending materials to a P. O. Box instead of your home address).

. Ask OPM to limit how your personal medical information is used or given out. However, OPM may not be able to agree to your request if the information is used to conduct operations in the manner described above.
. Get a separate paper copy of this notice.
For more information on exercising your rights set out in this notice, look at www. opm. gov/ insure on the web. You
may also call 202-606-0191 and ask for OPM's FEHB Program privacy official for this purpose.

If you believe OPM has violated your privacy rights set out in this notice, you may file a complaint with OPM at the
following address:

Privacy Complaints
Office of Personnel Management
P. O. Box 707
Washington, DC 20004-0707

Filing a complaint will not affect your benefits under the FEHB Program. You also may file a complaint with the
Secretary of the Department of Health and Human Services.

By law, OPM is required to follow the terms in this privacy notice. OPM has the right to change the way your
personal medical information is used and given out. If OPM makes any changes, you will get a new notice by mail
within 60 days of the change. 4.
4 Page 5 6
2004 Coventry Healthcare of Louisiana 2 Table of Contents
Table of Contents
Introduction…………………………………………………………………................................................................. 4
Plain Language……………………………………………………………… ............................................................... 4
Stop Health Care Fraud!.................................................................................................................................................. 5
Preventing Medical Mistakes.......................................................................................................................................... 6
Section 1. Facts about this HMO plan ........................................................................................................................... 7
How we pay providers .................................................................................................................................. 7
Your Rights................................................................................................................................................... 7
Service Area.................................................................................................................................................. 8
Section 2. How we change for 2004……………………………………….................................................................. 9
Program-wide changes…………………………………………………………………………………….. 9
Changes to this Plan...................................................................................................................................... 9
Section 3. How you get care …………... .................................................................................................................... 10
Identification cards...................................................................................................................................... 10
Where you get covered care........................................................................................................................ 10
. Plan providers....................................................................................................................................... 10
. Plan facilities ........................................................................................................................................ 10
What you must do to get covered care........................................................................................................ 10
. Primary care.......................................................................................................................................... 10
. Specialty care........................................................................................................................................ 10
. Hospital care......................................................................................................................................... 11
Circumstances beyond our control ............................................................................................................. 11
Services requiring our prior approval ......................................................................................................... 11
Section 4. Your costs for covered services .................................................................................................................. 12
. Copayments .......................................................................................................................................... 12
. Deductible............................................................................................................................................. 12
. Coinsurance .......................................................................................................................................... 12
Your catastrophic protection out-of-pocket maximum............................................................................... 12
Section 5. Benefits…………………………………………………………............................................................... 13
Overview..................................................................................................................................................... 13
(a) Medical services and supplies provided by physicians and other health care professionals ........... 14
(b) Surgical and anesthesia services provided by physicians and other health care professionals ....... 21
(c) Services provided by a hospital or other facility, and ambulance services ..................................... 25
(d) Emergency services/ accidents.......................................................................................................... 28
(e) Mental health and substance abuse benefits .................................................................................... 30
(f) Prescription drug benefits ................................................................................................................ 32
(g) Special Features ............................................................................................................................... 34
(h) Dental Benefits................................................................................................................................. 35 5.
5 Page 6 7
2004 Coventry Health Care of Louisiana, Inc. 3 Table of Contents
(i) Non-FEHB benefits available to Plan members .............................................................................. 36
Section 6. General exclusions --things we don't cover .............................................................................................. 37
Section 7. Filing a claim for covered services ............................................................................................................. 38
Section 8. The disputed claims process ....................................................................................................................... 39
Section 9. Coordinating benefits with other coverage................................................................................................. 41
When you have other health coverage........................................................................................................ 41
. What is Medicare?................................................................................................................................... 41
. Should I enroll in Medicare?…………………………………………………………………………… 41
. Medicare + Choice .................................................................................................................................. 44
. TRICARE and CHAMPVA.................................................................................................................... 44
. Workers Compensation........................................................................................................................... 45
. Medicaid.................................................................................................................................................. 45
. Other Government agencies.................................................................................................................... 45
. When others are responsible for injuries................................................................................................. 45
Section 10. Definitions of terms we use in this brochure ............................................................................................ 46
Section 11. FEHB facts................................................................................................................................................ 47

Coverage information ................................................................................................................................. 47
. No pre-existing condition limitation ................................................................................................... 47
. Where you can get information about enrolling in the FEHB Program.............................................. 47
. Types of coverage available for you and your family......................................................................... 47
. Children's Equity Act………………………………………………………………………...... …… 48
. When benefits and premiums start ....................................................................................................... 48
. When you retire ................................................................................................................................... 49
When you lose benefits............................................................................................................................... 49
. When FEHB coverage ends................................................................................................................. 49
. Spouse equity coverage ....................................................................................................................... 49
. Temporary Continuation of Coverage (TCC) ..................................................................................... 49
. Converting to individual coverage ...................................................................................................... 49
. Getting a Certificate of Group Health Plan Coverage......................................................................... 50
. Two new Federal Programs complement FEHB benefits .................................................................. 51
. The Federal Flexible Spending Account Program – FSAFEDS ........................................................ 51
. The Federal Long Term Care Insurance Program............................................................................... 54

Index ............................................................................................................................................................................. 56
Summary of benefits..................................................................................................................................................... 57
Notes ............................................................................................................................................................................. 58
Rates………………………………………………………………………………………………………….. Back cover 6.
6 Page 7 8
2004 Coventry Health Care of Louisiana, Inc. 4 Introduction
Introduction
This brochure describes the benefits of Coventry Health Care of Louisiana, Inc. under our contract (CS 2050) with
the United States Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits
law. The address for Coventry Health Care of Louisiana, Inc. administrative offices is:

Coventry Health Care of Louisiana, Inc.
2424 Edenborn Ave., Suite 350
Metairie, Louisiana 70001

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits,
limitations, and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self
and Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to
benefits that were available before January 1, 2004, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2004, and are
summarized on page 9. Rates are shown at the end of this brochure.

Plain Language
All FEHB brochures are written in plain language to make them responsive, accessible, and understandable to the
public. For instance,

. Except for necessary technical terms, we use common words. For instance, "you" means the enrollee or family member; "we" means Coventry Health Care of Louisiana, Inc..

. We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States Office of Personnel Management. If we use others, we tell you what they mean first.
. Our brochure and other FEHB plans' brochures have the same format and similar descriptions to help you compare plans.
If you have comments or suggestions about how to improve this brochure, let us know. Visit OPM's "Rate Us"
feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov. You may also write to OPM at
the United States Office of Personnel Management, Insurance Services Program, Program Planning and Evaluation
Group, 1900 E Street, NW Washington, DC 20415-3650. 7.
7 Page 8 9
2004 Coventry Health Care of Louisiana, Inc. 5 Advisory
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits (FEHB)
Program premium.

OPM's Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program
regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud – Here are some things you can do to prevent fraud:
. Be wary of giving your plan identification (ID) number over the telephone or to people you do not know, except to your doctor, other provider, or authorized plan or OPM representative.
. Let only the appropriate medical professionals review your medical record or recommend services. . Avoid using health care providers who say that an item or service is not usually covered, but they know how to
bill us to get it paid.
. Carefully review explanations of benefits (EOBs) that you receive from us. . Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or

service.
. If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or misrepresented any information, do the following:

. Call the provider and ask for an explanation. There may be an error. . If the provider does not resolve the matter, call us at 1-800/ 341-6613 and explain the situation.
. If we do not resolve the issue:

CALL --THE HEALTH CARE FRAUD HOTLINE
202-418-3300

OR WRITE TO: The United States Office of Personnel Management
Office of the Inspector General Fraud Hotline 1900 E Street, NW, Room 6400
Washington, DC 20415-1100

. Do not maintain as a family member on your policy: . Your former spouse after a divorce decree or annulment is final (even if a court order stipulates
otherwise); or
. Your child over 22 (unless he/ she is disabled and incapable of self support. . If you have any questions about the eligibility of a dependent, check with your personnel office if you are

employed , with your retirement office (such as OPM) if you retired, or with the National Finance Center if you
are enrolled under Temporary Continuation of Coverage.
. You can be prosecuted for fraud and your agency may take action against you if you falsify a claim to obtain FEHB benefits or try to obtain services for someone who is not an eligible family member or who is no longer

enrolled in the Plan. 8.
8 Page 9 10
2004 Coventry Health Care of Louisiana, Inc. 6 Preventing Medical Mistakes
Preventing Medical Mistakes
An influential report from the Institute of Medicine estimates that up to 98,000 Americans die every year from
medical mistakes in hospitals alone. That's about 3,230 preventable deaths in the FEHB Program a year. While death
is the most tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital
stays, longer recoveries, and even additional treatments. By asking questions, learning more and understanding your
risks, you can improve the safety of your own health care, and that of your family members. Take these simple steps:

1. Ask questions if you have doubts or concerns.
. Ask questions and make sure you understand the answers. . Choose a doctor with whom you feel comfortable talking.

. Take a relative or friend with you to help you ask questions and understand answers. 2. Keep and bring a list of all the medicines you take.
. Give your doctor and pharmacist a list of all the medicines that you take, including non-prescription medicines.
. Tell them about any drug allergies you have. . Ask about side effects and what to avoid while taking the medicine.
. Read the label when you get your medicine, including all warnings. . Make sure your medicine is what the doctor ordered and know how to use it.
. Ask the pharmacist about your medicine if it looks different than you expected. 3. Get the results of any test or procedure.
. Ask when and how you will get the results of test or procedures. . Don't assume the results are fine if you do not get them when expected, be it in person, by phone, or by
mail.
. Call your doctor and ask for your results. . Ask what the results mean for your care.

4. Talk to your doctor about which hospital is best for your health needs.
. Ask your doctor about which hospital has the best care and results for your condition if you have more than one hospital to choose from to get the health care you need.

. Be sure you understand the instructions you get about follow-up care when you leave the hospital. 5. Make sure you understand what will happen if you need surgery.
. Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
. Ask your doctor, "Who will manage my care when I am in the hospital?" . Ask your surgeon:
Exactly what will you be doing?
About how long will it take?
What will happen after surgery?
How can I expect to feel during recovery?
. Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications you are taking.

Want more information on patient safety?
www. ahrq. gov/ consumer/ pathqpack. htm. The Agency for Healthcare Research and Quality makes available
a wide-ranging list of topics not only to inform consumers about patient safety but to help choose quality
healthcare providers and improve the quality of care you receive.
www. npsf. org. The National Patient Safety Foundation has information on how to ensure safer healthcare
for you and your family.
www. talkaboutrx. org/ consumer. html. The National Council on Patient Information and Education is
dedicated to improving communication about the safe, appropriate use of medicines.
www. leapfroggroup. org. The Leapfrog Group is active in promoting safe practices in hospital care.
www. ahqa. org. The American Health Quality Association represents organizations and healthcare
professionals working to improve patient safety.
www. quic. gov/ report. Find out what federal agencies are doing to identify threats to patient safety and help
prevent mistakes in the nation's healthcare delivery 9.
9 Page 10 11
2004 Coventry Health Care of Louisiana, Inc. 7 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and
other providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely
responsible for the selection of these providers in your area. Contact the Plan for a copy of their most recent provider
directory.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in
addition to treatment for illness and injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may have to submit claim forms.

You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or
coinsurance.

If you have any questions regarding choosing a doctor, please call our Member Services Department at 800/ 341-6613.
The Plan's provider directory lists primary care doctors (generally family practitioners, pediatricians, and internists)
with their locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are
updated on a regular basis and are available at the time of enrollment or upon request by calling the Member Services
Department at 800/ 341-6613; you can also find out if your doctor participates with this Plan by calling this number. If
you are interested in receiving care from a specific provider who is listed in the directory, call the provider to verify
that he or she still participates with the Plan and is accepting new patients. Important note: When you enroll in this
Plan, services (except for emergency benefits) are provided through the Plan's delivery system; the continued
availability and/ or participation of any one doctor, hospital, or other provider, cannot be guaranteed.

If you are receiving services from a doctor who leaves the Plan, the Plan will pay for covered services until the Plan
can arrange with you for you to be seen by another participating doctor.

Your Rights
OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information
about us, our networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific types
of information that we must make available to you. Some of the required information is listed below.

. Coventry Health Care is a Federally qualified health maintenance organization (HMO) . Profit status – For profit

If you want more information about us, call 800/ 341-6613, or write to Coventry Health Care of Louisiana, Inc., 2424
Edenborn Ave., Suite 350, Metairie, LA 70001. You may also contact us by fax at 504/ 834-2694 or visit our website
at www. chclouisiana. com. 10.
10 Page 11 12
2004 Coventry Health Care of Louisiana, Inc. 8 Section1
Service Area
To enroll with us, you must live or work in our service area. This is where our providers practice.
New Orleans service area: Jefferson, Orleans, Plaquemines, St. Bernard, St. Charles and St. Tammany.
Baton Rouge service area: Ascension, Livingston, St. John the Baptist, East Baton Rouge, West Baton Rouge, Assumption, East Feliciana, Iberville, Lafayette, Pointe Coupee, St. Helena, St. James, Tangipahoa, Vermillion, West
Feliciana and Washington.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area,
we will pay only for emergency care benefits. We will not pay for any other health care services out of our service
area unless the services have prior plan approval.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your
dependents live out of the area (for example, if your child goes to college in another state), you should consider
enrolling in a fee-for-service plan or an HMO that has agreements with affiliates in other areas. If you or a family
member move, you do not have to wait until Open Season to change plans. Contact your employing or retirement
office. 11.
11 Page 12 13
2004 Coventry Health Care of Louisiana, Inc. 9 Section 2
Section 2. How we change for 2004
Do not rely on these change descriptions; this page is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout this brochure; any language change not shown here is a
clarification that does not change benefits.

Program-wide changes

. We added information regarding two new Federal Programs that complement FEHB benefits, the Federal Flexible Spending Account Program -FSAFEDS and the Federal Long Term Care Insurance Program. See
page 51.
. We added information regarding Preventing medical mistakes. See page 6. . We added information regarding enrolling in Medicare. See page 41.

. We revised the Medicare Primary Payer Chart. See page 43.

Changes to this Plan
. CODE JA -BATON ROUGE AREA -Your share of the non-Postal premium for Enrollment Code JA will increase by 43.4% for Self Only or 49.5% for Self and Family.

. CODE BJ -NEW ORLEANS AREA -Your share of the non-Postal premium for Enrollment Code BJ will decrease by 5.8% for Self Only or 5.8% for Self and Family.

. We have no benefit changes. 12.
12 Page 13 14
2004 Coventry Health Care of Louisiana, Inc. 10 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a prescription
at a Plan pharmacy. Until you receive your ID card, use your copy of the
Health Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at 800/ 341-
6613. You may also request replacement cards through our website at
www. chclouisiana. com

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, deductibles, and/ or coinsurance, and you will not have
to file claims.
. . . . Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update
periodically. This list is also on our website at www. chclouisiana. com.

. . . . Plan facilities Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members. We list these
in the provider directory, which we update periodically. This list is also
on our website at www. chclouisiana. com.

What you must do to get It depends on the type of care you need. covered care

. . . . Primary care Coventry does not require you to select a primary care physician
. . . . Specialty care You may see any specialist in the network without a referral.

Here are other things you should know about specialty care:
. If you have a chronic or disabling condition and lose access to your specialist because we:

. terminate our contract with your specialist for other than cause; or
. drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan, or
. reduce our service area and you enroll in another FEHB Plan.

you may be able to continue seeing your specialist for up to 90 days
after you receive notice of the change. Contact us, or if we drop out of
the Program, contact your new plan. 13.
13 Page 14 15
2004 Coventry Health Care of Louisiana, Inc. 11 Section 3
If you are in the second or third trimester of pregnancy and you lose
access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even
if it is beyond the 90 days.

. . . . Hospital care Your provider will make necessary hospital arrangements and supervise your care. This includes admission to a skilled nursing or other type of
facility.
If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 800/ 341-6613. If you
are new to the FEHB Program, we will arrange for you to receive care.

If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:

. You are discharged, not merely moved to an alternative care center; or
. The day your benefits from your former plan run out; or
. The 92 nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person. If
your plan terminates participation in the FEHB Program in whole or in
part, or if OPM orders an enrollment change, this continuation of
coverage provision does not apply. In such case, the hospitalized family
member's benefits under the new plan begin on the effective date of
enrollment.

Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them.
In that case, we will make all reasonable efforts to provide you with the
necessary care.

Services requiring our For certain services your physician must obtain approval from us. Before prior approval giving approval, we consider if the service is covered, medically
necessary, and follows generally accepted medical practice.
We call this review and approval process prior authorization. Your
physician must obtain prior authorization for the following services:
institution services such as a hospital stay.

Your physician must get the Plan's approval before sending you to a
hospital, or recommended follow-up care. Before giving approval, we
consider if the service is medically necessary, and if it follows generally
accepted medical practice.

If you obtain services from a specialist, hospital or other health care
provider, the services will be covered only if medically necessary and
authorized, except in the case of emergency medical services and urgent
care. Certain services, such as inpatient hospital services, outpatient
surgeries/ treatments, skilled nursing facilities, home health services,
durable medical equipment, certain diagnostic tests and subacute care
also require approval of the utilization review department before the
services are initiated. 14.
14 Page 15 16
2004 Coventry Health Care of Louisiana, Inc. 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
. . . . Copayments A copayment is a fixed amount of money you pay to the provider when you receive services.

Example: When you see your primary care physician you pay a
copayment of $15 per office visit. When you go in the hospital, you pay
$100 copay per day up to a $300 maximum per admission.

. . . . Deductible We do not have a deductible.
. . . . Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.

Example: In our plan, you pay 50% of our allowance for infertility
services and allergy testing.

Your catastrophic out-of-pocket maximum for
deductibles, coinsurance and copayments

After your coinsurance totals $1,000 per person or $3,000 per family
enrollment in any calendar year, you do not have to pay any more for
covered services. However, copayments do not count toward your out-of-
pocket maximum, and you must continue to pay copayments for those
services. The following does apply to your out of pocket:

. Allergy testing . Infertility Services

. Short-term Therapies 15.
15 Page 16 17
2004 Coventry Health Care of Louisiana, Inc. 13 Section 5
Section 5. Benefits --OVERVIEW
(See page 9 for how our benefits changed this year and page 57 for a benefits summary.)

NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us
at 800/ 341-6613 or at our website at www. chclouisiana. com.

(a) Medical services and supplies provided by physicians and other health care professionals ........................... 14-20
. Diagnostic and treatment services . Lab, X-ray, and other diagnostic tests
. Preventive care, adult . Preventive care, children
. Maternity care . Family planning
. Infertility services . Allergy care
. Treatment therapies . Physical and occupational therapies

. Speech therapy . Hearing services (testing, treatment, and
supplies)
. Vision services (testing, treatment, and supplies)

. Foot care . Orthopedic and prosthetic devices
. Durable medical equipment (DME) . Home health services
. Chiropractic

(b) Surgical and anesthesia services provided by physicians and other health care professionals ........................ 21-24
. Surgical procedures . Reconstructive surgery . Oral and maxillofacial surgery . Organ/ tissue transplants
. Anesthesia

(c) Services provided by a hospital or other facility, and ambulance services ...................................................... 25-27
. Inpatient hospital
. Outpatient hospital or ambulatory surgical center
. Extended care benefits/ skilled nursing care facility benefits

. Hospice care . Ambulance

(d) Emergency services/ accidents .......................................................................................................................... 28-29
. Medical emergency

. Ambulance
(e) Mental health and substance abuse benefits ..................................................................................................... 30-31
(f) Prescription drug benefits................................................................................................................................. 32-33
(g) Special Features..................................................................................................................................................... 34
(h) Dental Benefits ...................................................................................................................................................... 35

(i) Non-FEHB benefits available to Plan members.................................................................................................... 36
Summary of benefits..................................................................................................................................................... 57 16.
16 Page 17 18
2004 Coventry Health Care of Louisiana, Inc. 14 Section 5
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

. Plan physicians must provide or arrange your care.
. Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians
. In physician's office

. Specialists' consultation

$15 per office visit

Professional services of physicians
. In an urgent care center
. Office medical consultations
. Second surgical opinion

$15 per office visit

. At home $25 per visit
Lab, X-ray and other diagnostic tests You pay
Such as:
. Blood tests
. Urinalysis
. Non-routine pap tests
. Pathology
. X-rays
. Non-routine Mammograms
. CAT. Scans/ MRI
. Ultrasound
. Electrocardiogram and EEG

Nothing 17.
17 Page 18 19
2004 Coventry Health Care of Louisiana, Inc. 15 Section 5
Preventive care, adult You pay
Routine screenings, such as
. Blood lead level – One annually
. Total Blood Cholesterol – once every three years, ages 19 through 64
. Colorectal Cancer Screening, including
. Fecal occult blood test

$15 per office visit

Sigmoidoscopy, screening – every five years starting at age 50 $15 per office visit
Routine Prostate Specific Antigen (PSA) test – one annually for men age 40
and older $15 per office visit

Routine pap test $15 per office visit
Routine mammogram –covered for women age 35 and older, as
follows:

. From age 35 through 39, one during this five year period
. From age 40 through 64, one every calendar year
. At age 65 and older, one every two consecutive calendar years

$15 per office visit

Routine immunizations, limited to:
. Tetanus-diphtheria (Td) booster – once every 10 years, ages 19 and over (except as provider for under Childhood immunizations)

. Influenza vaccine, annually
. Pneumococcal vaccine, age 65 and over

$15 per office visit

Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel for both
children and adults.

All charges.

Preventive care, children
. Childhood immunizations recommended by the American Academy of Pediatrics

. Examinations done on the day of immunizations ( under age 22)
$15 per office visit

. Well-child care charges for routine examinations, immunizations and care under age 22)
. Examinations, such as:
. Eye exams through age 17 to determine the need for vision correction.

. Ear exams through age 17 to determine the need for hearing

$15 per office visit 18.
18 Page 19 20
2004 Coventry Health Care of Louisiana, Inc. 16 Section 5
Maternity care You pay
Complete maternity (obstetrical) care, such as:
. Prenatal care
. Delivery
. Postnatal care
Note: Here are some things to keep in mind:
. You do not need to precertify your normal delivery; see page 11 for other circumstances, such as extended stays for you or your baby.

. You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend
your inpatient stay if medically necessary.
. We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other

care of an infant who requires non-routine treatment only if we
cover the infant under a Self and Family enrollment.

. We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and

Surgery benefits (Section 5b).

$15 per office visit

Family planning
A range of voluntary family planning services, limited to:
. Surgically implanted contraceptives (such as Norplant)
. Injectable contraceptive drugs (such as Depo provera)
. Diaphragm (fitting only)

Note: We cover oral contraceptives under the prescription drug benefit.

$15 per office visit

. Voluntary sterilization (vasectomy or tubal ligation) $100 per procedure
Not covered: reversal of voluntary surgical sterilization, genetic
counseling, or Intrauterine devices (IUDs).
All charges.

Infertility services
Diagnosis and treatment of infertility, such as:
. Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)

50% of charges 19.
19 Page 20 21
2004 Coventry Health Care of Louisiana, Inc. 17 Section 5
Infertility services (continued) You pay
Not covered:
. Assisted reproductive technology (ART) procedures, such as:
in vitro fertilization
embryo transfer, gamete GIFT and zygote ZIFT
Zygote transfer
. Services and supplies related to excluded ART procedures

. Cost of donor sperm
. Cost of donor egg
. Fertility drugs

All charges.

Allergy care
Testing
Allergy injection and treatments
50% of charges

$15 per office visit
Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges.

Treatment therapies
. Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 23.

. Respiratory and inhalation therapy
. Dialysis – hemodialysis and peritoneal dialysis
. Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy

. Oxygen for home use and equipment
. Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit

$15 per office visit 20.
20 Page 21 22
2004 Coventry Health Care of Louisiana, Inc. 18 Section 5
Physical and occupational therapies You pay
. 60 days per condition for the services of each of the following:
. physical therapists and
. occupational therapists.
Note: We only cover therapy to restore bodily function when there
has been a total or partial loss of bodily function due to illness or
injury.

. Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction, is provided for up to 60 days, for physical

therapy

20% of charges

Not covered:
. long-term rehabilitative therapy
. exercise programs

All charges.

Speech therapy
. 60 days per condition 20% of charges

Hearing services
. Hearing testing for children through age 17 $15 per office visit
Not covered: hearing aids All charges.

Vision services
. Diagnosis and treatment of diseases of the eye $15 per office visit

. Prosthetic devices, such as lenses following cataract removal 50% of charges
Not covered:
. Eyeglasses or contact lenses or the fitting of contact lenses
. Eye exercises and orthoptics
. Radial keratotomy and other refractive surgery

. Annual eye refractions

All charges. 21.
21 Page 22 23
2004 Coventry Health Care of Louisiana, Inc. 19 Section 5
Foot care You pay
Routine foot care when you are under active treatment for a metabolic
or peripheral vascular disease, such as diabetes.

See orthopedic and prosthetic devices for information on podiatric shoe
inserts.

$15 per office visit

Not covered:
. Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot,

except as stated above
. Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the

treatment is by open cutting surgery)

All charges.

Orthopedic and prosthetic devices
Our maximum allowance for this benefit is $1,000 per calendar year
. Artificial limbs and eyes
. Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

. Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy. Note: See 5( b) for coverage of the surgery
to insert the device.

. Orthopedic devices, such as braces
. Foot orthotics
. Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Nothing up to our maximum
allowance of $1,000 per calendar
year

Not covered:
. heel pads and heel cups
. lumbosacral supports
. corsets, trusses, elastic stockings, support hose, and other supportive devices

All charges. 22.
22 Page 23 24
2004 Coventry Health Care of Louisiana, Inc. 20 Section 5
Durable medical equipment (DME) You pay
Our maximum allowance for this benefit is $1,000 per calendar year

Rental or purchase, at our option, including repair and adjustment, of
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:

. hospital beds;
. wheelchairs;
. crutches;
. walkers;
. blood glucose monitors; and
. insulin pumps.

Note: Call us at 800/ 341-6613 as soon as your Plan physician
prescribes this equipment.

Nothing up to our maximum
allowance of $1,000 per calendar
year

Not covered: Motorized wheel chairs All charges.
Home health services
. Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), or licensed
vocational nurse (L. V. N.).
. Services include oxygen therapy, intravenous therapy and medications.

Nothing

Not covered:
. nursing care requested by, or for the convenience of, the patient or the patient's family;

. home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic or
rehabilitative .
. Nursing aides

All charges.

Chiropractic
. Manipulation of the spine and extremities

After initial evaluation, treatment plan must be submitted to Coventry
Health Care to authorize additional visits.

$15 per office visit 23.
23 Page 24 25
2004 Coventry Health Care of Louisiana, Inc. 21 Section 5
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

. Plan physicians must provide or arrange your care.
. Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

Medicare.
. The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5( c) for charges associated with the facility (i. e. hospital, surgical

center, etc.).
. YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION OF SOME SURGICAL PROCEDURES. Please refer to the prior authorization information shown in Section 3 to be sure

which services require prior authorization and identify which surgeries require precertification.

I M
P O
R T
A N
T

Benefit Description You pay
Surgical procedures
A comprehensive range of services, such as:
. Operative procedures
. Treatment of fractures, including casting
. Normal pre-and post-operative care by the surgeon
. Endoscopy procedures
. Biopsy procedures
. Removal of tumors and cysts
. Correction of congenital anomalies (see reconstructive surgery)
. Surgical treatment of morbid obesity – a condition in which an individual weighs 100 pounds or over 100% over his or her normal

weight according to current underwriting standards; eligible
members must be age 18 or over

. Insertion of internal prostethic devices. See 5( a) – Orthopedic and prosthetic devices for device coverage information.

. Treatment of burns

$15 per office visit 24.
24 Page 25 26
2004 Coventry Health Care of Louisiana, Inc. 22 Section 5
Surgical procedures (Continued) You pay
Voluntary sterilization (e. g., Tubal ligation, Vasectomy) $100 per procedure

Not covered:
. Reversal of voluntary sterilization

. Routine treatment of conditions of the foot; see Foot care.

All charges.

Reconstructive surgery
. Surgery to correct a functional defect
. Surgery to correct a condition caused by injury or illness if:
. the condition produced a major effect on the member's appearance and

. the condition can reasonably be expected to be corrected by such surgery
. Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities, cleft lip and
cleft palate; birth marks webbed fingers; and webbed toes.

$15 per office visit

. All stages of breast reconstruction surgery following a mastectomy, such as:
. surgery to produce a symmetrical appearance on the other breast;
. treatment of any physical complications, such as lymphedemas;
. breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.

See above.

Not covered:
. Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance

through change in bodily form, except repair of accidental injury
. Surgeries related to sex transformation

All charges. 25.
25 Page 26 27
2004 Coventry Health Care of Louisiana, Inc. 23 Section 5
Oral and maxillofacial surgery You pay
Oral surgical procedures, limited to:
. Reduction of fractures of the jaws or facial bones; . Surgical correction of cleft lip, cleft palate or severe functional

malocclusion;
. Removal of stones from salivary ducts; . Excision of leukoplakia or malignancies;

. Excision of cysts and incision of abscesses when done as independent procedures; and
. Other surgical procedures that do not involve the teeth or their supporting structures.

. TMJ treatment and services (non-dental)

$15 per office visit

Not covered:
. Oral implants and transplants
. Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

. Dental care involved in treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

All charges

Organ/ tissue transplants
Limited to:
. Cornea
. Heart
. Heart/ lung
. Kidney
. Kidney/ Pancreas
. Liver
. Lung: Single –Double
. Pancreas
. Allogeneic (donor) bone marrow transplants

. Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors

. Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver,
stomach, and pancreas.
Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI approved clinical
trial at a Plan-designated center of excellence and if approved by the
Plan's medical director in accordance with the Plan's protocols.

Note: We cover related medical and hospital expenses of the donor when
we cover the recipient.

$15 per office visit 26.
26 Page 27 28
2004 Coventry Health Care of Louisiana, Inc. 24 Section 5
Not covered:
. Donor screening tests and donor search expenses, except those performed for the actual donor

. Implants of artificial organs
. Transplants not listed as covered

All charges.

Anesthesia You pay
Professional services provided in -

. Hospital (inpatient) Nothing
Professional services
. Hospital outpatient department
. Skilled nursing facility . Ambulatory surgical center

. Office

$15 per office visit 27.
27 Page 28 29
2004 Coventry Health Care of Louisiana, Inc. 25 Section 5
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T

Here are some important things to remember about these benefits:
. Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are

medically necessary.
. Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

. Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about
coordinating benefits with other coverage, including with Medicare.
. The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs

associated with the professional charge (i. e., physicians, etc.) are covered in
Sections 5( a) or (b).

. YOUR PHYSICIAN MUST GET PRIOR AUTHORIZATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services

require prior authorization.

I M
P O
R T
A N
T

Benefit Description You pay
Inpatient hospital
Room and board, such as
. ward, semiprivate, or intensive care accommodations; . general nursing care; and

. meals and special diets.

NOTE: If you want a private room when it is not medically necessary,
you pay the additional charge above the semiprivate room rate.

$100 per day up to a $300
maximum per admission and
nothing for other services 28.
28 Page 29 30
2004 Coventry Health Care of Louisiana, Inc. 26 Section 5
Inpatient hospital (continued) You pay
Other hospital services and supplies, such as:
. Operating, recovery, maternity, and other treatment rooms . Prescribed drugs and medicines

. Diagnostic laboratory tests and X-rays . Administration of blood and blood products
. Dressings, splints, casts, and sterile tray services . Medical supplies and equipment, including oxygen
. Anesthetics, including nurse anesthetist services . Take-home items
. Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home (Note: calendar year
deductible applies.)

Nothing for other hospital services
after you pay the hospital
admission copayment.

Not covered:
. Custodial care . Non-covered facilities, such as nursing homes, schools

. Personal comfort items, such as telephone, television, barber services, guest meals and beds
. Blood . Private nursing care

All charges.

Outpatient hospital or ambulatory surgical center
. Operating, recovery, and other treatment rooms $50 copayment

. Prescribed drugs and medicines . Diagnostic laboratory tests, X-rays, and pathology services
. Administration of blood, blood plasma, and other biologicals . Pre-surgical testing
. Dressings, casts, and sterile tray services . Medical supplies, including oxygen
. Anesthetics and anesthesia service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

Nothing

Not covered: blood and blood derivatives not replaced by the member All charges. 29.
29 Page 30 31
2004 Coventry Health Care of Louisiana, Inc. 27 Section 5
Extended care benefits/ skilled nursing care facility benefits You pay
Comprehensive range of benefits will be provided for up to 100 days
per calendar year when full-time skilled nursing care is necessary and
confinement in a skilled nursing facility is in lieu of hospitalization..

Covered services include:
. Bed, board and general nursing care
. Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan

doctor.

Nothing

Not covered: custodial care All charges.
Hospice care
Supportive and palliative care for a terminally ill member in the home
or hospice facility. Services include inpatient and outpatient care, and
family counseling. Services are provided under the direction of a Plan
doctor who certifies that the patient is in the terminal stages of illness,
with a life expectancy of approximately six months or less.

Nothing

Not covered: Independent nursing, homemaker services All charges.
Ambulance
. Benefits are provided for ambulance transportation when ordered or authorized by a Plan doctor $50 per transport 30.
30 Page 31 32
2004 Coventry Health Care of Louisiana, Inc. 28 Section 5
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

. Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.

I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
endangers your life or could result in serious injury or disability, and requires immediate medical or
surgical care. Some problems are emergencies because, if not treated promptly, they might become more
serious; examples include deep cuts and broken bones. Others are emergencies because they are
potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability
to breathe. There are many other acute conditions that we may determine are medical emergencies – what
they all have in common is the need for quick action.

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to
tell the emergency room personnel that you are a Plan member so they can notify the Plan.
If you need to be hospitalized in a non-Plan facility, the Plan must be notified within 24 hours or on the first
working day following your admission, unless it was not reasonably possible to notify the Plan within that
time. If you are hospitalized in non-Plan facilities and Plan doctors believe care can be better provided in a
Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching a
Plan provider would result in death, disability or significant jeopardy to your condition.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by
the Plan or provided by Plan providers.

Emergencies outside our service area: Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified within 24 hours or on the first working day following
your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor
believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with
any ambulance charges covered in full.

To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by
the Plan or provided by Plan providers. 31.
31 Page 32 33
2004 Coventry Health Care of Louisiana, Inc. 29 Section 5
Benefit Description You pay
Emergency within our service area

. Emergency care at a doctor's office $15 per office visit
. Emergency care as an outpatient or inpatient at a hospital, including doctors' services $50 per visit

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area
. Emergency care at a doctor's office $15 per office visit

. Emergency care as an outpatient or inpatient at a hospital, including doctors' services $50 per visit

Not covered:
. Elective care or non-emergency care
. Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

. Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges.

Ambulance
. Benefits are provided for ambulance transportation when ordered or authorized by a Plan doctor $50 per transport 32.
32 Page 33 34
2004 Coventry Health Care of Louisiana, Inc. 30 Section 5
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T

When you get our approval for services and follow a treatment plan we approve, cost-sharing
and limitations for Plan mental health and substance abuse benefits will be no greater than for
similar benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits:
. Please remember all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

. Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.
. YOU MUST GET PRIOR AUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I M
P O
R T
A N
T

Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.

Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.

Your cost sharing
responsibilities are no
greater than for other illness
or conditions.

. Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers

. Medication management

$15 per office visit

Mental health and substance abuse benefits continued on next page. 33.
33 Page 34 35
2004 Coventry Health Care of Louisiana, Inc. 31 Section 5
Mental health and substance abuse benefits (continued) You pay
. Diagnostic tests Nothing

. Services provided by a hospital or other facility
. Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment

We may allow Members to exchange one inpatient day of treatment for four
(4) outpatient visits or exchange four (4) outpatient visits for one inpatient
day of treatment. We may also allow a Member to exchange two (2) days
of Transitional Partial Hospitalization or two (2) days of residential
treatment center hospitalization for each inpatient day of treatment.

$100 per day up to a $300
maximum per admission

Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans on the
treatment plan's clinical appropriateness. OPM will generally not
order us to pay or provide one clinically appropriate treatment plan in
favor of another.

All charges.

Preauthorization To be eligible to receive these benefits you must obtain a treatment plan and follow all our authorization processes. To receive a mental health referral, please call 1-800-245-
8327.

Limitation We may limit your benefits if you do not obtain a treatment plan. 34.
34 Page 35 36
2004 Coventry Health Care of Louisiana, Inc. 32 Section 5
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
. We cover prescribed drugs and medications, as described in the chart beginning on the next page.

. All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
. Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.

I M
P O
R T
A N
T
. There are important features you should be aware of. These include:
. Who can write your prescription. A Plan physician must write the prescription.
. Where you can obtain them. You must fill the prescription at a contracted Plan pharmacy or by mail for maintenance medication.

. We use a formulary. We use a committee of doctors, pharmacists and other health care professionals to develop a formulary that gives you access to quality medications. FDA-approved brand-name and
generic medications are reviewed for safety, side effects, effectiveness and overall value. We
continually update the formulary based on the latest research. If your doctor prescribes a medication
that is not on the list, you can get that medication, but you will share in a greater portion of the cost.

. These are the dispensing limitations. The quantity of each prescription is limited to that sufficient to treat the acute phase of illness or a 30-day supply maximum, whichever is less, per copayment.

Members called to active military duty in a time of national or other emergency who need to obtain a greater-than-normal supply of prescribed medications should call 1-866-320-0697.

. Mail Order. You can obtain through Mail Order covered "maintenance" prescription drugs use to treat chronic or long-term health conditions such as high blood pressure or diabetes) for a 90-day supply. You
pay $20 copay per prescription unit or refill for formulary generic drugs, $40 copay for formulary name
brand drugs and $90 for non formulary.

Prescription drug benefits begin on the next page. 35.
35 Page 36 37
2004 Coventry Health Care of Louisiana, Inc. 33 Section 5
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy:

. Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except as excluded
below.
. Insulin . Insulin syringes and medication

. Disposable needles and syringes for the administration of covered medications
. Drugs for sexual dysfunction (see Note below) . Contraceptive drugs and devices
. Growth hormones
Note: Contact the Plan for drug dose limits for sexual dysfunction.

Retail Pharmacy
$10 per generic
$20 per formulary name brand
$45 per non-formulary
Mail Order (Maintenance medications only)

$20 per generic
$40 per formulary name brand
$90 per non-formulary
Note: If there is no generic
equivalent available, you will still
have to pay the brand name copay.

Here are some things to keep in mind about our prescription drug
program:

. A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a
name brand drug when a Federally-approved generic drug is
available, you have to pay the difference in cost between the name
brand drug and the generic.

. We administer a formulary. If your physician believes a name brand product is necessary or there is no generic available, your
physician may prescribe a name brand drug from a formulary list.
This list of name brand drugs is a preferred list of drugs that we
selected to meet patient needs at a lower cost. You must pay a $45
copay for a non-formulary drug. To order a prescription drug
brochure, call 800/ 341-6613.

Not covered:
. Drugs and supplies for cosmetic purposes
. Drugs to enhance athletic performance
. Fertility drugs
. Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies

. Vitamins and nutritional substances that can be purchased without a prescription
. Nonprescription medicines

All charges. 36.
36 Page 37 38
2004 Coventry Health Care of Louisiana, Inc. 34 Section 5
Section 5 (g). Special features
Flexible benefits option Under the flexible benefits option, we determine the most effective way to provide services.
. We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less

costly alternative benefit.
. Alternative benefits are subject to our ongoing review.
. By approving an alternative benefit, we cannot guarantee you will get it in the future.

. The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular
contract benefits.
. Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.

24 hour nurse line For any of your health concerns, 24 hours a day, 7 days a week, you may call First Help at 1-800-622-9528 and talk with a registered nurse who will discuss treatment options and answer your health
questions. 37.
37 Page 38 39
2004 Coventry Health Care of Louisiana, Inc. 35 Section 5
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
. Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

. Plan dentists must provide or arrange your care.
. We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient. See Section 5 (c) for inpatient hospital benefits.

We do not cover the dental procedure unless it is described below.
. Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with Medicare.

I M
P O
R T
A N
T
Accidental injury benefit You pay

We cover restorative services and supplies necessary to promptly repair
(but not replace) sound natural teeth. The need for these services must
result from an accidental injury.

$15 per office visit 38.
38 Page 39 40
2004 Coventry Health Care of Louisiana, Inc. 36 Section 5
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.

Vision care You are eligible to receive substantial discounts on eyeglasses, contact lenses and non-prescription items such as sunglasses and contact lens
solutions. Please read the flyer that describes your extra Vision Care
benefit.

Dental care You are eligible to receive substantial discounts on dental care, including diagnostic and preventative, restorative, crowns, endodontics, peridontics,
prosthodontics and orthodontics. Please read the accompanying flyer that
describes Dental Care benefits available through this program.

Health Club You are eligible to receive discount memberships from participating health clubs. 39.
39 Page 40 41
2004 Coventry Health Care of Louisiana, Inc. 37 Section 6
Section 6. General exclusions --things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we
will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition.

We do not cover the following:
. Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);

. Services, drugs, or supplies you receive while you are not enrolled in this Plan;
. Services, drugs, or supplies that are not medically necessary;
. Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

. Experimental or investigational procedures, treatments, drugs or devices;
. Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or

incest;
. Services, drugs, or supplies related to sex transformations;
. Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;
. Services, drugs, or supplies you receive without charge while in active military service. 40.
40 Page 41 42
2004 Coventry Health Care of Louisiana, Inc. 38 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment or
coinsurance.

You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these
providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and
assistance, call us at 800/ 341-6613.

When you must file a claim --such as for services you receive outside of
the Plan's service area --submit it on the HCFA-1500 or a claim form
that includes the information shown below. Bills and receipts should be
itemized and show:

. Covered member's name and ID number;
. Name and address of the physician or facility that provided the service or supply;

. Dates you received the services or supplies;
. Diagnosis;
. Type of each service or supply;
. The charge for each service or supply;
. A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice (MSN); and

. Receipts, if you paid for your services.
Submit your claims to: CHC Louisiana/ Claims
P. O. Box 7707
London, KY 40742

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you
received the service, unless timely filing was prevented by administrative
operations of Government or legal incapacity, provided the claim was
submitted as soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 41.
41 Page 42 43
2004 Coventry Health Care of Louisiana, Inc. 39 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies – including a request for preauthorization:

Step Description

1 Ask us in writing to reconsider our initial decision. You must: (a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: CHC Louisiana, Inc., 2424 Edenborn Ave., Suite 350, Metairie, LA 70001;
and

(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and

(d) Include copies of documents that support your claim, such as physicians' letters, operative reports,
bills, medical records, and explanation of benefits (EOB) forms.

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of
our request— go to step 3.

3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days. If we do not receive the information within 60 days, we will decide within 30 days of the date the
information was due. We will base our decision on the information we already have.
We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it. You must write to OPM within:
. 90 days after the date of our letter upholding our initial decision; or
. 120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
. 120 days after we asked for additional information.

Write to OPM at: United States Office of Personnel Management, Insurance Services Program,, Health
Insurance Group 3, 1900 E Street, NW, Washington, D. C. 20415-3630. 42.
42 Page 43 44
2004 Coventry Health Care of Louisiana, Inc. 40 Section 8
The Disputed Claims process (Continued)
Send OPM the following information:
. A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

. Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
. Copies of all letters you sent to us about the claim;
. Copies of all letters we sent to you about the claim; and
. Your daytime phone number and the best time to call.

Note: If you want OPM to review more than one claim, you must clearly identify which documents apply
to which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific written consent with the
review request.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because
of reasons beyond your control.

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other administrative appeals.
If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file
the suit against OPM in Federal court by December 31 of the third year after the year in which you received
the disputed services, drugs or supplies or from the year in which you were denied precertification or prior
approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim
decision. This information will become part of the court record.

You may not sue until you have completed the disputed claims process. Further, Federal law governs your
lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of
benefits in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at
800/ 341-6613 and we will expedite our review; or

(b) We denied your initial request for care or preauthorization/ prior approval, then:
. If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

. You may call OPM's Health Insurance Group 3 at 202/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 43.
43 Page 44 45
2004 Coventry Health Care of Louisiana, Inc. 41 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you or a covered family member have coverage under another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance
Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in this
brochure.

When we are the secondary payer, we will determine our allowance.
After the primary plan pays, we will pay what is left of our allowance, up
to our regular benefit. We will not pay more than our allowance.

What is Medicare? Medicare is a Health Insurance Program for:
. People 65 years of age and older.
. Some people with disabilities, under 65 years of age.
. People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:
. Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your spouse worked for at least 10 years in Medicare-covered

employment, you should be able to qualify for premium-free
Part A insurance. (Someone who was a Federal employee on January
1, 1983 or since automatically qualifies.) Otherwise, if you are 65 or
older, you may be able to buy it. Contact 1-800-MEDICARE for more
information.

. Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B premiums are withheld from your monthly Social

Security check or your retirement check.
The decision to enroll in Medicare is yours. We encourage you to apply
for Medicare benefits 3 months before you turn age 65. It's easy. Just
call the Social Security Administration toll-free number 1-800-772-1213
to set up an appointment to apply. If you do not apply for one or both
Parts of Medicare, you can still be covered under the FEHB Program.

If you can get premium-free Part A coverage, we advise you to enroll in
it. Most Federal employees and annuitants are entitled to Medicare Part
A at age 65 without cost. When you don't have to pay premiums for
Medicare Part A, it makes good sense to obtain the coverage. It can
reduce your out-of-pocket expenses as well as costs to the FEHB, which
can help keep FEHB premiums down.

Everyone is charged a premium for Medicare Part B coverage. The
Social Security Administration can provide you with premium and
benefit information. Review the information and decide if it makes sense
for you to buy the Medicare Part B coverage.

Should I enroll in Medicare? 44.
44 Page 45 46
2004 Coventry Health Care of Louisiana, Inc. 42 Section 9
If you are eligible for Medicare, you may have choices in how you get
your health care. Medicare + Choice is the term used to describe the
various health plan choices available to Medicare beneficiaries. The
information in the next few pages shows how we coordinate benefits
with Medicare, depending on the type of Medicare managed care plan
you have.

The Original Medicare Plan (Part A or B) The Original Medicare Plan (Original Medicare) is available everywhere in the United States. It is the way everyone used to get Medicare benefits
and is the way most people get their Medicare Part A and Part B benefits
now. You may go to any doctor, specialist, or hospital that accepts
Medicare. The Original Medicare Plan pays its share and you pay your
share. Some things are not covered under Original Medicare, like
prescription drugs. When you are enrolled in Original Medicare along
with this plan, you still need to follow the rules in this brochure for us to
cover your care.

Claims process when you have the Original Medicare Plan --You probably will never have to file a claim form when you have both our
Plan and the Original Medicare Plan.
. When we are the primary payer, we process the claim first.
. When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claim will be coordinated
automatically and we will then provide secondary benefits for
covered charges. You will not need to do anything. To find out if
you need to do something to file your claim, call us at 1-800-341-
6613.

We waive some costs if the Original Medicare Plan is your primary payer --We will waive some out-of-pocket costs as follows:
Office visit copayments
( Primary payer chart begins on the next page.) 45.
45 Page 46 47
2004 Coventry Health Care of Louisiana, Inc. 43 Section 9
Medicare always makes the final determination as to whether they are the primary payer. The following chart illustrates whether
Medicare or this Plan should be the primary payer for you according to your employment status and other factors determined by
Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can administer these
requirements correctly

Primary Payer Chart
The primary payer for the individual with Medicare is… A. When you -or your covered spouse -are age 65 or over and have Medicare and you…

Medicare This Plan
1) Are an active employee with the Federal government and…
. You have FEHB coverage on your own or through your spouse who is also an active employee

. You have FEHB coverage through your spouse who is an annuitant
2) Are an annuitant and…
. You have FEHB coverage on your own or through your spouse who is also an annuitant

. You have FEHB coverage through your spouse who is an active employee
3) Are a reemployed annuitant with the Federal government and your position is excluded
from the FEHB (your employing office will know if this is the case) *

4) Are a reemployed annuitant with the Federal government and your position is not excluded
from the FEHB (your employing office will know if this is the case) and…
. You have FEHB coverage on your own or through your spouse who is also an active employee

. You have FEHB coverage through your spouse who is an annuitant
5) Are a Federal judge who retired under title 28, U. S. C., or a Tax Court judge who
retired under Section 7447 of title 26, U. S. C. (or if your covered spouse is this type of
judge)
*

6) Are enrolled in Part B only, regardless of your employment status for Part
B services
for other services

7) Are a former Federal employee receiving Workers' Compensation and the Office of
Workers' Compensation Programs has determined that you are unable to return to
duty)
**

B. When you or a covered family member…
1) Have Medicare solely based on end stage renal disease (ESRD) and…
. It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD (30-month coordination period)

. It is beyond the 30-month coordination period and you or a family member are still entitled to Medicare due to ESRD
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary
and…
. This Plan was the primary payer before eligibility due to ESRD for 30-month coordination period

. Medicare was the primary payer before eligibility due to ESRD C. When either you or your spouse are eligible for Medicare solely due to disability

and you
1) Are an active employee with the Federal government and…
. You have FEHB coverage on your own or through your spouse who is also an active employee

. You have FEHB coverage through your spouse who is an annuitant 2) Are an annuitant and…
. You have FEHB coverage on your own or through your spouse who is also an annuitant
. You have FEHB coverage through your spouse who is an active employee
D. Are covered under the FEHB Spouse Equity provision as a former spouse

* Unless you have FEHB coverage through your spouse who is an active employee
** Workers' Compensation is primary for claims related to your condition under Workers' Compensation 46.
46 Page 47 48
2004 Coventry Health Care of Louisiana, Inc. 44 Section 9
. . . . Medicare + Choice If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare + Choice plan. These are health care choices
(like HMOs) in some areas of the country. In most Medicare + Choice plans, you
can only go to doctors, specialists, or hospitals that are part of the plan. Medicare
+ Choice plans provide all the benefits that Original Medicare covers. Some cover
extras, like prescription drugs. To learn more about enrolling in a Medicare +
Choice plan, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov.

If you enroll in a Medicare + Choice plan, the following options are available to
you:

This Plan and another plan's Medicare + Choice plan: You may enroll in another plan's Medicare+ Choice plan and also remain enrolled in our FEHB plan.
We will still provide benefits when your Medicare+ Choice plan is primary, even
out of the Medicare + Choice plan's network and/ or service area (if you use our
Plan providers), but we will not waive any of our copayments, coinsurance, or
deductibles. If you enroll in a Medicare + Choice plan, tell us. We will need to
know whether you are in the Original Medicare Plan or in a Medicare + Choice
plan so we can correctly coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare + Choice plan: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in
a Medicare + Choice plan, eliminating your FEHB premium. (OPM does not
contribute to your Medicare+ Choice plan premium.) For information on
suspending your FEHB enrollment, contact your retirement office. If you later
want to re-enroll in the FEHB Program, generally you may do so only at the next
open season unless you involuntarily lose coverage or move out of the Medicare +
Choice plan's service area.

TRICARE and CHAMPVA TRICARE is the health care program for eligible dependents of military persons, and retirees of the military. TRICARE includes the CHAMPUS program.
CHAMPVA provides health coverage to disabled Veterans and their eligible
dependents. If TRICARE or CHAMPVA and this Plan cover you, we pay first.
See your TRICARE or CHAMPVA Health Benefits Advisor if you have
questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in
a one of these programs, eliminating your FEHB premium. (OPM does not
contribute to any applicable plan premiums.) For information on suspending your
FEHB enrollment, contact your retirement office. If you later want to re-enroll in
the FEHB Program, generally you may do so only at the next Open Season unless
you involuntarily lose coverage under the program. 47.
47 Page 48 49
2004 Coventry Health Care of Louisiana, Inc. 45 Section 9
Workers' Compensation We do not cover services that:
. you need because of a workplace-related illness or injury that the Office of Workers' Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or
. OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your care. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored program of medical assistance: If you are an annuitant or
former spouse, you can suspend your FEHB coverage to enroll in one of
these State programs, eliminating your FEHB premium. For information
on suspending your FEHB enrollment, contact your retirement office. If
you later want to re-enroll in the FEHB Program, generally you may do
so only at the next Open Season unless you involuntarily lose coverage
under the State program.

When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you for medical or hospital care for injuries for injuries or illness caused by another person, you must reimburse us
for any expenses we paid. However, we will cover the cost of treatment
that exceeds the amount you received in the settlement.

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 48.
48 Page 49 50
2004 Coventry Health Care of Louisiana, Inc. 46 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 12.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 12.
Covered services Care we provide benefits for, as described in this brochure.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for
those services. See page 12.

Experimental or A health product or service is deemed experimental or investigational investigational services and excluded from coverage under this Agreement if one or more of the
following conditions are met: (i) any drug not approved for use by the
FDA; any drug that is classified as IND (investigational new drug) by the
FDA; (ii) any drug requiring pre-authorization that is proposed for off-label
prescribing; (iii) any health product or service that is subject to
Investigational Review Board (IRB) review or approval; (iv) any health
product or service that is subject of a clinical trial that meets criteria for
Phase I, II or III as set forth by FDA regulations; or (v) any health
product or service that does not have a demonstrated value based on
clinical evidence reported by peer-review medical literature and by
generally recognized academic experts.

Group health coverage If you leave the FEHB Program, we will give you a Certificate of Group Health Plan Coverage that indicates how long you have been enrolled
with us. You can use this certificate when getting health insurance or
other health care coverage. You must arrange for the other coverage
within 63 days of leaving this Plan. Your new plan must reduce or
eliminate waiting periods, limitations or exclusions for health related
conditions based on the information in the certificate.

If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may request a certificate
from them, as well.

Us/ We Us and we refer to Coventry Health Care of Louisiana, Inc.
You You refers to the enrollee and each covered family member. 49.
49 Page 50 51
2004 Coventry Health Care of Louisiana, Inc. 47 Section 11
Section 11. FEHB facts
Coverage information
No pre-existing condition We will not refuse to cover the treatment of a condition that you had limitation before you enrolled in this Plan solely because you had the condition
before you enrolled.
Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office about enrolling in the can answer your questions, and give you a Guide to Federal Employees

FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about your FEHB coverage. These
materials tell you:
. When you may change your enrollment;
. How you can cover your family members;
. What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire;

. When your enrollment ends; and
. When the next open season for enrollment begins.
We don't determine who is eligible for coverage and, in most cases,
cannot change your enrollment status without information from your
employing or retirement office.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for for you and your family you, your spouse, and your unmarried dependent children under age 22,
including any foster children or stepchildren your employing or
retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event.
The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When
you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office
receives your enrollment form; benefits will not be available to your
spouse until you marry.

Your employing or retirement office will not notify you when a family
member is no longer eligible to receive health benefits, nor will we.
Please tell us immediately when you add or remove family members
from your coverage for any reason, including divorce, or when your child
under age 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan. 50.
50 Page 51 52
2004 Coventry Health Care of Louisiana, Inc. 48 Section 11
Children's Equity Act OPM has implemented the Federal Employees Health Benefits Children's Equity Act of 2000. This law mandates that you be enrolled for Self and
Family coverage in the Federal Employees Health Benefits (FEHB)
Program, if you are an employee subject to a court or administrative
order requiring you to provide health benefits for your child( ren).

If this law applies to you, you must enroll for Self and Family coverage
in a health plan that provides full benefits in the area where your children
live or provide documentation to your employing office that you have
obtained other health benefits coverage for your children. If you do not
do so, your employing office will enroll you involuntarily as follows:

. If you have no FEHB coverage, your employing office will enroll you for Self and Family coverage in the option of the Blue Cross and
Blue Shield Service Benefit Plan Basic Option;
. If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves the area where your children live, your employing

office will change your enrollment to Self and Family in the same
option of the same plan; or
. If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to

Self and Family in the lower option of the Blue Cross and Blue
Shield Service Benefit Plan Basic Option.

As long as the court/ administrative order is in effect, and you have at
least one child identified in the order who is still eligible under the FEHB
Program, you cannot cancel your enrollment, change to Self Only, or
change to a plan that doesn't serve the area in which your children live,
unless you provide documentation that you have other coverage for the
children. If the court/ administrative order is still in effect when you
retire, and you have at least one child still eligible for FEHB coverage,
you must continue your FEHB coverage into retirement (if eligible) and
cannot cancel your coverage, change to Self Only, or change to a plan
that doesn't serve the area in which your children live as long as the
court/ administrative order is in effect. Contact your employing office for
further information.

When benefits and The benefits in this brochure are effective on January 1. If you joined premiums start this Plan during Open Season, your coverage begins on the first day of
your first pay period that starts on or after January 1. If you changed
plans or plan options during Open Season and you receive care between
January 1 and the effective date of coverage under your new plan or
option, your claims will be paid according to the 2004 benefits of your
old plan or option. However, if your old plan left the FEHB Program at
the end of the year, you are covered under that plan's 2003 benefits until
the effective date of your coverage with your new plan. Annuitants'
coverage and premiums begin on January 1. If you joined at any other
time during the year, your employing office will tell you the effective
date of coverage. 51.
51 Page 52 53
2004 Coventry Health Care of Louisiana, Inc. 49 Section 11
When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years
of your Federal service. If you do not meet this requirement, you may be
eligible for other forms of coverage, such as Temporary Continuation of
Coverage (TCC).

When you lose benefits
. . . . When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional premium, when:

. Your enrollment ends, unless you cancel your enrollment, or
. You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary
Continuation of Coverage (TCC), or a conversion policy (a non-FEHB
individual policy).

. . . . Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue to get benefits under your former spouse's enrollment. This is
the case even when the court has ordered your former spouse to supply
health coverage to you. But, you may be eligible for your own FEHB
coverage under the spouse equity law or Temporary Continuation of
Coverage (TCC). If you are recently divorced or are anticipating a
divorce, contact your ex-spouse's employing or retirement office to get
RI 70-5, the Guide to Federal Employees Health Benefits Plans for
Temporary Continuation of Coverage and Former Spouse Enrollees, or
other information about your coverage choices. You can also download
the guide from OPM's website, www. opm. gov/ insure.

. . . . Temporary continuation If you leave Federal service, or if you lose coverage because you no of coverage (TCC) longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if
you are not able to continue your FEHB enrollment after you retire, if
you lose your job, or if you are a covered dependent child and you turn
22 or marry, etc.

You may not elect TCC if you are fired from your Federal job due to
gross misconduct.